COVID-19 AND CRITICAL CARE: WHAT PROVIDERS NEED TO …

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COVID-19 ANDCRITICAL CARE:

WHAT PROVIDERSNEED TO KNOWMAY 1, 2020 UPDATE

Sue Hansen, MSN RNTrauma/Surgery Critical Care Clinical Nurse Specialist

Harborview Medical CenterSeattle, WA

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COVID-19 Keeping Up With A Moving Target

Every Wednesday Evening

Every Friday Morning

Now, Twice Every Week @ COVID19.DKBmed.com

CME Information

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Jointly provided by Postgraduate Institute for Medicine, DKBmed, and the Institute

for Johns Hopkins Nursing.

Disclosure of Conflicts of InterestPostgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and other individuals who are in a

position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as

related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM i s

committed to providing its learners with high quality activities and related materials that promote improvements or quality

in healthcare and not a specific proprietary business interest of a commercial interest.

The faculty reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

Name of Faculty or Presenter Reported Financial Relationship

Sue Hansen, MSN, RN None

There will be no references to the unlabeled/unapproved uses of any drugs or products in today’s discussion. All activity,

content, and materials have been developed solely by the activity directors, planning committee members, and faculty

presenters, and are free of influence from a commercial entity. All activity, content, and materials have been developed

solely by the activity directors, planning committee members, and faculty presenters, and are free of influence from a

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CME Information

To attest for CME/CE credit, please visit

COVID19.DKBmed.com

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Learning Objectives

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• Describe two indications for mechanical ventilation

• Distinguish between commonly used modes of

mechanical ventilation

• State two common ventilatory alarms and the causes for

each.

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Sue Hansen, MSN RNTrauma/Surgery Critical Care

Clinical Nurse SpecialistHarborview Medical Center

Seattle, WA

This program is brought to you through the

generous support of DKBmed, Postgraduate

Institute for Medicine, and the Institute for

Johns Hopkins Nursing.

Please see COVID19.DKBmed.com for

additional resources and educational

activities

Thank You

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Ventilator Management for Beginners: Part I

Agenda

• Indications for mechanical ventilatory support

• Mechanical ventilation (MV) and common terminology

• Common modes & settings of mechanical ventilation

• Common ventilator alarms & monitoring parameters

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MV in COVID-19

Richardson S et al., JAMA, 2020

MV-320/5700 (12%)Died- 553/5700 (21%)MV + Died-88%

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• 18/24 (75%)

• 23% bilateral patchy infiltrates

• 21 % had ground glass opacities

• Day 1 FiO2-90%

Bhatraju BK et al., NEJM, 2020

MV in COVID-19

• Duration of MV 10 days• Mortality rate 12/24 (50%)• Age > 65% = 62%

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Indications

• Airway control

• Impaired oxygenation & ventilation

• Procedural

• Acute respiratory failure⎯ Trauma

⎯ Cardiac arrest

• Chronic respiratory failure⎯ Neuromuscular disorders

⎯ Central nervous system disorders/injuries

⎯ Pulmonary disorders

Patel B.K., Merck ’s Manual, 2020

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MV - It’s All About The Pressures

• Normal physiologic breathing occurs through a negative

pressure circuit: air is pulled into the lungs by pressure

gradients

• Mechanical ventilation is completely opposite process

• Positive pressure system: air is forcefully pushed air into

the lungs by a machine

Lodeserto F, REBEL EM, 2019

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MV “Terminology”

• Mode

• Respiratory rate (RR)

• Tidal volume (Vt)

• Minute ventilation (Ve)

• Plateau pressure (PP)

• Sensitivity

• I:E ratio

• FiO2

• Positive end expiratory pressure (PEEP)

• Compliance

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Modes of MV

Volume Cycled (VC)

(Volume Control-CMV or AC)

VC & PC

(SIMV + PS)

Pressure Cycled (PC)

(Pressure Control-PC)

Santanilla JL, Emerg. Med. Clin. Essen., 2013

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Assist Control (AC)

Synchronized Intermittent Mandatory

Ventilation (SIMV)

Common Modes of MV

Santanilla JL, Emerg. Med. Clin. Essen., 2013

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Pressure Support Ventilation (PSV)

SIMV + PS

Common Modes of MV

Santanilla JL, Emerg. Med. Clin. Essen., 2013

Common Ventilator Alarms

• High peak pressure

• Low peak pressure

• Low exhaled Vt

• High minute ventilation (Ve)

•Dislodgement

•Obstruction

•Pneumothorax

•Equipment failure

Cvach M, et al., Respir. Care, 2018

Weingart S, Em Crit, 2019 17

Monitoring Parameters

• Compliance

• Plateau Pressures (Pplat)

• Work of breathing (WOB)

• P/F ratio

• Driving pressure-( P )

• Peak airway pressure-(PAP)

To submit your own question for Sue, please email

[email protected]

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What are major complications associated with mechanical ventilation in COVID patients?

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What can be done to prevent

ventilator-associated pneumonia?

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How are patients moved to and from operating rooms in crisis situations while using mechanical ventilation?

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Can we use pressure control mode (PRVC) on the ventilator when proning COVID-19 patients?

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What are the disadvantages of using pressure control mode (PRVC)?

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What are the advantages of using

ACVC mode for COVID-19 patients?

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To receive CME/CE credit:

• Complete the evaluation on at COVID19.DKBmed.com

• Upon registering and successfully completing the activity

evaluation, you will have immediate access to your

certificate.

To access more resources related to COVID-19:

• Access our resource hub at COVID19.DKBmed.com

To ask your own question to Sue:

• Email [email protected]